On January 17, 2023, CMS published the annual list of items that require a face-to-face encounter and written order prior to delivery (WOPD). The published list includes 10 additional orthoses codes that will require a require a face-to-face encounter and written order prior to delivery as a condition of payment, effective April 17, 2023.
|
HCPCS |
Description |
|
L0631 |
Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior and Posterior Panels, Posterior Extends from Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure to Reduce Load On the Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized to Fit A Specific Patient By An Individual With Expertise. |
|
L0637 |
Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panels, Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise. |
|
L1843 |
Knee Orthosis, Single Upright, Thigh and Calf, With Adjustable Flexion and Extension Joint (Unicentric or Polycentric), Medial-Lateral and Rotation Control, With or Without Varus/Valgus Adjustment, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise. |
|
L1932 |
Ankle Foot Orthosis, Rigid Anterior Tibial Section, Total Carbon Fiber or Equal Material, Prefabricated, Includes Fitting and Adjustment. |
|
L1940 |
Ankle Foot Orthosis, Plastic or Other Material, Custom-Fabricated. |
|
L1951 |
Ankle Foot Orthosis, Spiral, (Institute of Rehabilitative Medicine Type), Plastic or Other Material, Prefabricated, Includes Fitting and Adjustment. |
|
L1960 |
Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom-Fabricated. |
|
L1970 |
Ankle Foot Orthosis, Plastic with Ankle Joint, Custom-Fabricated. |
|
L2005 |
Knee Ankle Foot Orthosis, Any Material, Single or Double Upright, Stance Control, Automatic Lock and Swing Phase Release, Any Type Activation, Includes Ankle Joint, Any Type, Custom Fabricated. |
|
L2036 |
Knee Ankle Foot Orthosis, Full Plastic, Double Upright, With or Without Free Motion Knee, With or Without Free Motion Ankle, Custom Fabricated. |
Of the above ten codes, all are in the OR01 or OR02 categories, which are categorized as prefabricated, custom fitted (OR02) or custom fabricated (OR01). Items in these categories may require the use of a licensed/certified orthotist or prosthetist in order to furnish orthoses. Payment edits have been put in place to ensure the supplier is appropriately enrolled with the correct specialty code(s). These edits currently apply to 21 states: Alabama, Arkansas, Connecticut, Florida, Georgia, Idaho, Illinois, Iowa, Kentucky, Maryland, Minnesota, Mississippi, Nevada, New Jersey, North Dakota, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, and Washington.
See below for more information on WOPD an F2F requirements.
Written Order Prior to Delivery (WOPD) Requirements
For items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, a complete order is required prior to the item’s delivery. (For all other DMEPOS items, the order is required prior to claim submission.)
Face-to-Face Encounter requirements applicable to certain DMEPOS items:
- For all items requiring a face-to-face encounter, a practitioner visit is required within six months preceding the order. Note: face-to-face encounters for PMDs were previously required within 45 days preceding the written order.
- The encounter must be used to gather subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
- The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective, beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
- If the encounter is performed via telehealth, the requirements for telehealth services and payment for telehealth services must be met.
- A supplier must maintain the written order/prescription and the supporting documentation provided by the treating practitioner and make them available to CMS and its agents upon request.
For more information, please refer to the CMS website on Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Order Requirements.